During an assessment, the nurse determines a patient is demonstrating symptoms of a psychosis. What did the nurse assess in this patient?
1. The patient says, "The servants need to be disciplined."
2. The patient says, "The voice told me to cut myself."
3. The patient laughs when asked about the health of a family member hospitalized for cancer treatment.
4. The patient asks to close the room door so "that man can't get to me."
5. The patient says, "I have not been able to get any sleep for months."
Correct Answer: 1,2,3,4
Rationale 1: This statement is an example of a grandiose delusion.
Rationale 2: This statement is an example of an auditory hallucination.
Rationale 3: During a psychotic episode, the patient's mood and affect may vary widely and be inappropriate, such as laughing at sad events.
Rationale 4: This statement is an example of a delusion in which someone is trying to harm the patient.
Rationale 5: The lack of sleep is not a symptom of psychosis.
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Of these behaviors observed by the nurse, the ones documented as re-gression are (select all that apply): 1. talking nonstop to staff and other residents. 2. wets and soils self several times a day. 3. wakes in the middle of the night and can't return to sleep. 4. wears the same clothes day after day. 5. cries frequently for no apparent reason.